Summary:
This blog is about the mental health of children and young people, specifically the role schools might play in trying to support youngsters, resulting from gaps in provision elsewhere. Such gaps are currently glaring, especially in Child and Adolescent Mental Health Services (CAMHS), and the pandemic has apparently made things worse. The first part of the blog cites various sources to provide an overview of the key pressures for young people, both pre and post pandemic.
The second part focuses on that cohort of children and young people who are known to have more serious mental health needs, but who are either stuck on a CAMHS waiting list, or who do not meet the existing criteria for any help from CAMHS. In such cases it most often falls to families and schools to ‘hold the fort’ until specialist interventions can begin, or to ‘pick up the pieces’ when a request for help is turned down. The blog goes on to argue that implementing a full Social, Emotional and Mental Health Policy would help educational institutions- at a strategic and operational level- to bolster their existing mental health support for youngsters, and make sure this is more consistent.
Length: 2,700 words.

The background.
Even before the pandemic, there was general cause for concern about the overall mood of our youngsters. As the Department for Education’s 2020 ‘State of the Nation’ report said, “the wellbeing of children in England and the UK remains relatively low compared with other countries and with decreasing trends over time (The Children’s Society, 2020b; Sizmur et al., 2019; UNICEF, 2020).”
In the most recent OECD/PISA report (2018), 15 year olds in the UK scored below the international average on PISA’s measures for general mood and outlook.
Many children and young people with more serious mental health issues require secondary care, typically consisting of a referral from a GP to a specialist service. Even before the pandemic access to such services was not good. CAMHS and related mental health service providers do excellent work, of course, however, the data suggests that CAMHS is an under-resourced service nationally. The charity Young Minds reported in 2018 that “less than 1% of the total NHS budget is spent on CAMHS, and only 8.7% of the total mental health budget goes on under-18s”. In 2015 the government pledged an extra £1.4 billion of spending on CAMHS, and Young Minds found that “the investment has led to substantial extra spending on children’s mental health in almost every CCG across the country”. Funding increases are welcome, but far less welcome was their finding that “these budget increases are not consistent.” For example, some NHS clinical commissioning groups increased CAMHS budgets by less than had been allocated for the purpose.
Barriers to accessing CAMHS services exist. A report by the Education Policy Institute (January 2020) reported how young people fared once referred for an initial CAMHS assessment. It said “over a quarter (26%) of referrals to specialist children’s mental health services were rejected in 2018-2019. This amounts to approximately 133,000 children and young people.” Furthermore, “rejection rates have not improved over the last four years, despite an extra £1.4bn committed from 2015-16 to 2020-21.”
Waiting times for youngsters accepted by CAMHS give cause for concern. The EPI’s key finding for waiting times in 2019 was that “children still waited an average of two months (56 days) to begin treatment in 2019 – double the government’s four-week target.” It adds that government “is unlikely to meet its target of four weeks by 2022-23″.
Comparing regions, the EPI found “the longest median waiting times to receive treatment were in London (65 days) and the shortest in the Midlands and East of England (49 days).” However, itadds that there are great disparities across local CAMHS providers, with many children facing waiting times that are much longer than the regional averages: “Median waiting times for treatment across mental health providers varied from just 1 day to 6 months (182 days).” In some areas and for some kinds of treatment, waiting times are even longer than six months. While this kind of gap between referral and starting treatment can occur to any child regardless of background, the EPI points out that “several providers reported that the longest waiting times, in some cases of over a year, were experienced by vulnerable children who face barriers to engaging with services.”
By vulnerable we typically mean factors like being from a lower income background, being in a deprived area, or having Special Educational Needs and Disabilities.
Just imagine the stress involved when a child falls into all three categories.

The ‘Pandemic effect’

What might the pandemic have added to an already bleak picture?
In September 2020, The Co-Space study published its findings on changes in mental health symptoms among children in its study group, over a one-month period early in lockdown. It found “in primary school aged children, there were mean increases in emotional, behavioural and restlessness/inattention difficulties.” Startlingly, it added that “the proportion of children likely to have significant difficulties (i.e., meet diagnostic criteria for a clinical diagnosis) in these 3 areas also increased, by up to 35%.” For “young people of secondary school age, there was a reduction in emotional difficulties, no change in behavioural difficulties and a slight increase in restlessness/inattention. The proportion of young people within this age range likely to have significant emotional difficulties did not change but did increase for difficulties with behaviour and restlessness/inattention.” The Study found that “for children and young people from low-income households, emotional and attention difficulties (and behaviour difficulties for primary school aged children) were consistently elevated compared to those from higher income households, with around two and a half times as many children experiencing significant problems in low-income households.”
In July 2020 NHS digital published a study which attempted to compare the mental health of children and young people between 2017 and 2020, and also to describe life during the pandemic. Among the headline findings were that in 2020, 1 in 6 children (16%) between the age of 5 and 16 were identified as having a probable mental disorder (up from 1 in 9 in 2017). About six in 10 of these children were found to have regular support from their school or college under normal circumstances. Those children with a disorder were more likely to say that lockdown had made their life worse.
In terms of young people seeking help for the first time, the January 2021 report from the Children’s Commissioner quotes early NHS data which suggests “referrals to mental health services dipped early on in lockdown, but subsequently soared in early Autumn 2020. In April referrals were 34% lower than in the same month in 2019. In September they were 72% higher than in September 2019.” One can imagine the effect that this will have on waiting lists that were already long.
Finally, the charity Young Minds indicates levels of support that young people with existing mental health conditions have received since March 2020, both within school and from CAMHS. Reports show the picture is mixed. Of the approximately 2000 respondents to a Summer 2020 Covid survey, 80% reported the pandemic had made their mental health worse. Furthermore, “among more than 1,000 respondents who were accessing mental health support in the three months leading up the crisis (including from the NHS, school and university counsellors, private providers, charities and helplines), 31% said they were no longer able to access support but still needed it.”
Young Minds’ follow up report from September 2020- based again on approximately 2000 responses- found 69% describing their mental health as poor upon returning to school, up from 58% who described their mental health as poor before the return. In terms of support, 40% of respondents said that there was no school counsellor available to support students in their school. Only 27% had had a one-to-one conversation with a teacher or another member of staff. The other headline finding was that almost a quarter of respondents (23%) said that there was less mental health support in their school than before the pandemic, while only 9% agreed that there was more mental health support.
It’s worth considering that the impact of lockdown on mood and mental health may not have been entirely negative for every child, especially where the issues and general anxieties may have been caused by school in the first place. Take a Sussex University study, giving the perspectives on the first lockdown of 502 parents and carers of children with SEND. It found that “most of the children in the survey felt less stressed and anxious while at home during lockdown”. However, this should be seen in the broader context of a lack of other support services (for example reduced or no access to therapies and respite care), so not all SEND families will have experienced an overall drop in stress. A follow up study by the same team taking account of subsequent lockdowns will be due later in 2021.
Before we move on, it should be pointed out how in many cases CAMHS services have made the transition to online and other remote forms of delivery, so the picture is not entirely negative. While on a waiting list, CAMHS often identify services young people can access while on a waiting list (Kooth is commonly mentioned in this context), although of course there is no guarantee that every young person will make use of such services.

Where do schools fit into this?

Let’s go back to the two cohorts we mentioned at the start. First those children and young people requiring interim support, either because they have been accepted by CAMHS and are on a waiting list, or because treatment has been disrupted by the pandemic.
Then there’s those 25% of youngsters identified by the EPI study, whose needs warranted a CAMHS referral, but who did not reach the assessment threshold to receive specialist help.
It’s clear that there are many schools and school staff who do great work in supporting children and young people in such difficult situations. However, the range and quality of provision may differ from one school to the next. What I hope would motivate us all to greater collective efforts is the thought that we want any child, wherever he or she goes to school, to be well cared for, and for the staff to be properly supported in this aim.
I would like there to be a statutory requirement for every school to have a Social, Emotional and Mental Health (SEMH) policy. This sounds onerous, but some schools already have them, some have experimented with them, and a useful guide to putting one together (alongside a wealth of other useful resources) can be found at the Mentally Healthy Schools website. The key us to make such a policy a document that really works.
On the strategic level, there is scope for Local Authorities and Multi Academy Trust to request greater consistency from schools in their focus on SEMH, by ensuring good practice across a local area, and making sure it is properly embedded within schools. School Improvement Partners and a school’s own CPD programme can ensure that there is adequate focus on SEMH, so that teachers and support staff feel empowered to play a role in supporting young people.
Governing boards have a part to play, by taking ownership of the mental health issue, and supporting schools. A SEMH policy could play a role here. It could contain details about what a school already does to promote SEMH, and could also be used to identify gaps in provision, set targets, identify where extra provision can be accessed, establish protocols for working with pupils, and also for liaising with parents and other external agencies. It’s also crucial to outline how a SEMH policy works alongside pre-existing policies, like those relating to SEND, Inclusion, Attendance, and Bullying. This is just a small overview of what a working policy could contain, but it gives a flavour of what a flexible policy can do to focus efforts.
At the operational level, within educational institutions and delivered by staff, there is much good work done in schools at a general, preventative level. Social and Emotional Learning (SEL) has taken root in the last few years for instance. (However, a question remains for LEAs and MATs here: are all of the schools under your watch incorporating SEL via recognised programmes into the curriculum?)
What of the individual child in need? Think again of that youngster desperate for help, but not knowing when her CAMHS treatment will start. Or of the young man who expected he to get specialist help, but was told he won’t get any. Many schools have trained mental health first aiders. The concept of the mental health first aider has gained ground in recent years, and training is often free to access. I suggest that every school should have at least two mental health first aiders. Support staff are ideal people to take on these roles, since they are not so tied to the classroom. However, it’s unclear if such provision is consistent across all schools. Schoolsweek recently reported on a 2017 government a scheme offering mental health awareness training to every secondary school over three years. When it ended in March 2020, 27,710 of England’s 3,456 state secondary schools had completed the training. Arguably, there needs to be some form of statutory requirement for training in this area.
Can schools and colleges provide counselling? There’s an extra cost implication of course, so schools should be proactive in accessing counselling for individual students where this is available through the local authority, although even here there can be waiting lists. A school should know what additional support is available in a local area and nationally (most often through charities) and feel comfortable in signposting families towards these, in accordance with existing safeguarding procedures. There is a strong argument for encouraging teaching and support staff to undertake training in basic counselling skills, however. The idea wouldn’t be to train them as counsellors, but to equip them with basic listening skills for engaging with students as needed.
I stress again that many schools already do many of these things. Some even have a member of staff with SEMH within his or her remit. But in order to ensure complete consistency in all settings, and to make sure the protocols are satisfactory and being monitored, a good SEMH policy would enable these issues to be drawn together in one useful document, and make sure that any child in any school has access to some kind of support, rather than being left to just ‘get on with it’ alone.
Finally, I would like to add that a good SEMH policy would mention staff wellbeing as well, but the details of this are outside the scope of this post.

The bigger picture

It’s clear that CAMHS is struggling. Waiting times are all too often far too long. The Pandemic has piled more pressure on young people and the services they need. Meanwhile, schools must continue to do their best in even more trying circumstances.
The 2021 Childrens Commissioner’s report cited above addresses the impact of government programmes (three major initiatives in the last five years) which pledged to improve children’s and young people’s mental health provision and outcomes. The recommendations from the Commissioner’s report are clear, as is the message that government must be far more ambitious in its aims and strict in meeting its targets.
A new report published in January 2021 from the Education Policy Institute also provides clear policy recommendations, most of which are aimed at tightening up existing school-based provision and bolstering links with CAMHS.
These recommendations, along with many others made by similar organisations and third sector bodies, would all make for a far better system, and one better equipped to tackle the long-term effects of Covid-19 on mental health. The pandemic’s effect on the mood of young people, and the likely increase in demand for mental health services, means that existing plans for all CAMHS and related services need to be scaled up accordingly as a matter of absolute priority.

Mark Williams is Secretary of the Fabian Education Policy Group. A qualified teacher and experienced school governor, he takes a keen interest in the whole area of children and young people’s mental health.